Provider Demographics
NPI:1063227064
Name:SWAIN, LAILA NICOLE
Entity type:Individual
Prefix:
First Name:LAILA
Middle Name:NICOLE
Last Name:SWAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 W 17TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206-2711
Mailing Address - Country:US
Mailing Address - Phone:904-413-2504
Mailing Address - Fax:
Practice Address - Street 1:997 ATLANTIC BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32233-3311
Practice Address - Country:US
Practice Address - Phone:904-647-1849
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-08
Last Update Date:2025-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB1272579106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician